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Healthy Carolinians Partnership Support Initiative -Applicant Information Sheet (continued) <br />We have attached athree-year budget indicating expenses and revenues <br />consistent with the guidelines in the Initiative information sheet. <br />Our Fiscal year is July 1st to June 30th <br />Month Month <br />January 1, 200 December 31, ~ <br />Our Project year is to <br />Month Month <br />The following counties are included in our Partnership: <br />Orange <br />Our rip •mary areas of health-related program interests are: <br />CHECK ALL THAT APPLY <br />Access to Health Care <br />Chronic Disease <br />~ Healthy Eyes <br />~ Health Promotion and Risk Reduction <br />(~ Infant Mortality <br />r Infectious Disease <br />Injury Prevention and Control <br />-~ Mental Health <br />r Older Adults <br />l- Oral Health <br />Other(s)- Specify: <br />Potential focus areas based on <br />Community Health Assessment: <br />- Environmental Health <br />- Risky Teen Behaviors <br />We have attached responses to the three application questions. (see page 3) <br />Please sign in the spaces provided below: <br />Executive Director <br />(Rosemary Summers, DrPH <br />Print/Type Name <br />Board Chair or other authorized signature <br />(Matthew Vizithum, O.D <br />Print/Type-Name <br />Date <br /> <br />Date <br />Page 2 of 4 <br />